Advances in Wound Management

ABSTRACT:There are numerous wound dressings and
management techniques available today. These include absorbent
dressings, films, hydrocolloids, hydrogels, foams, antibiotic dressings,
larvae (maggot) therapy, and vacuum-assisted wound closure. The
challenge lies not only in choosing the correct dressing, but also in
using the chosen technique properly. This involves careful assessment of
the wound, taking into account its size, the exudate, and the patient’s
preferences. Health care professionals require basic knowledge of
dressings for correct application, and the wound should be monitored
closely to ensure effective healing.

A wound can be described as any process that leads to the disruption of the normal architecture and function of the tissue.1
It may be a closed wound such as a bruise or sprain or an open wound
such as an abrasion, laceration, avulsion, or ballistic or surgical
wound.2 This article discusses the management of wounds that cause a break in the skin’s integrity, i.e., open wounds.

A wound needs to be thoroughly assessed before an
appropriate dressing regimen can be drawn up. The wound is often
classified based upon the number of skin layers affected (TABLE 1).2

Wound Healing

Wound healing is a highly complex process that results in the restoration of cell structures and tissue layers after an injury.3
It involves interdependent and overlapping cellular, physiological,
biochemical, and molecular processes that can be divided into three
phases: inflammation, proliferation, and maturation.2,3 An acute wound will usually heal within a few weeks, whereas chronic wounds take longer than 6 weeks to heal.3

Inflammation:Part of the body’s
normal defense mechanism, the inflammatory phase is essential to the
healing process and occurs within seconds of injury. This stage can last
up to 3 days and is typically associated with redness, heat, swelling,
and pain.4

There is immediate vasoconstriction of the damaged blood vessels and coagulation to limit blood loss.3
Platelets are attracted to the damaged blood vessels and the
coagulation cascade is initiated, leading to a platelet plug that is
later stabilized by fibrin.3 Following this, histamine and other chemical mediators are released from the dam-aged cells, resulting in vasodilation.4
Vasodilation releases growth factors and brings white blood cells
(WBCs) to the area, leading to the release of other chemical mediators
that are essential for wound healing.3 Some of these mediators increase capillary permeability, causing exudate to be released into the wound area.4

Exudate is a broad term used to describe the fluid
that is produced by wounds following hemostasis. It consists primarily
of water and may include proteins, electrolytes, nutrients, proteases,
growth factors, WBCs, platelets, and inflammatory mediators.5 Healthy exudate is pale amber in color, odorless, and watery and is a sign of healing.5
Unhealthy wound exudate is associated with an excessive volume and/or
an altered content. If left unmanaged, it can lead to periwound skin
maceration, delayed healing, malodor, and infection.5,6 Neutrophils in the exudate serve to remove foreign material and dead or dying cells and attract macrophages to the area.3

Proliferation:Also known as the fibroblastic or regenerative phase, proliferation typically lasts 2 to 3 weeks.7
Granulation tissue composed of macrophages, fibroblasts, immature
collagen, blood vessels, and ground substance is formed. Fibroblasts
play two roles in the wound healing process: 1) they stimulate the
production of collagen and elastin that increases the strength of the
wound, and 2) they stimulate the growth of new blood vessels.3
As granulation tissue fills the wound site, the edges of the wound pull
together, decreasing the surface of the wound. Epithelialization is the
final step, whereby epithelial cells migrate from the wound edges and
the wound is finally covered, resulting in the formation of a scar.7

Maturation:The maturation phase can take anywhere from 3 weeks to 2 years.3 During this phase, collagen fibers cross link and reorganize, and the strength of the scar increases.2,7 Various local and systemic factors that can delay the wound healing process are listed in TABLE 2.2,3,8

Wound Dressings

Topical preparations for wound care have been used for
centuries. Dressings play a major role in wound management and have
developed greatly over the last 50 years from passive to more active
types.9 The first dressings used in the 18th century were
made from natural materials such as oakum. These dressings were
absorbent but could not retain the exudate, caused infections, and
adhered to the wound bed.5 This led to the development of Gamgee, an absorbent cotton wool core sandwiched between two layers of absorbent cotton gauze.5 In the 19th and 20th centuries, synthetic ingredients were increasingly used in the manufacture of dressings.7

Types of Dressings

While no single dressing meets all of the ideal criteria,
there are a range of dressings that vary in shape and size, the level of
exudate they can handle, and the anatomical site to which they can be
applied. Selecting the most appropriate dressing for the wound in
question is important.

Hydrocolloid, hydrogel, film, and foam dressings are able
to handle large amounts of exudate and promote auto-debridement, while
alginate and collagen-based dressing are mostly used for their ability
to promote granulation tissue.9 Antibiotic-based dressings
(e.g., neomycin, silver, iodine) have been developed in an attempt to
avoid infections, one of the main causes of delayed wound healing.9 Such dressings, however, run the risk of allergy and resistance.9
Advances in wound management have led to the development of active
dressings that facilitate the wound healing process as well as of
techniques such as vacuum-assisted closure to remove cytokines and
proteases.8 Primary dressings cover the wound directly, whereas secondary dressings are used to hold a primary dressing in place.3

Absorbent Dressings:Absorbent
dressings have a capillary action that wicks away mild, moderate, or
heavy drainage from wounds. These types of dressings help prevent the
periwound area from becoming macerated.11 They may be used as
primary or secondary dressings. Those without an adhesive border are
usually changed once daily, whereas those with an adhesive border may be
changed every other day.11

Hydrogels:Hydrogels consist of a matrix of hydrophilic polymers that swell in water but do not themselves dissolve.12,13 They contain about 60% to 90% water and are available as gels, sheets, and impregnated nonwoven dressings.3,11 Hydrogel wound dressings are effective, comfortable, easy to use, and cost-effective.14 Some hydrogel sheets have an adhesive border, but most require a secondary dressing.11

Hydrogels are useful for wounds with minimal or no
exudate, painful wounds, burns, and skin tears, since they hydrate the
wound surface and in some cases absorb excess exudate.13,14
This ability allows desloughing and debriding processes to necrotic and
fibrotic tissue. Hydrogels are soothing, cooling, and may even reduce
pain and thus are particularly useful when applied to radiation burns.3

On the downside, the high water content of hydrogels may
lead to maceration around the wound area. It is therefore important that
no more than the required amount of dressings be applied to the wound.3
Hydrogels contain propylene glycol, a chemical that is contraindicated
before larvae therapy. Wounds that are to be treated using larvae
therapy should therefore be free of hydrogels and thoroughly irrigated
24 hours before therapy. Hydrogel dressings are changed between 1 and 3
times a week.13,14

Hydrocolloids:Occlusive and adhesive
wafer dressings are usually made by bonding sodium
carboxy-methylcellulose, pectin, or gelatin to a carrier of
semipermeable or foam material and are used to manage light-to-moderate
amounts of wound exudate.12,13 Most hydrocolloids react with
the wound exudate to form a gel-like covering that protects the wound
bed and maintains a moist wound environment.13 In this way, they promote debridement of necrotic tissue.13

Hydrocolloids are available in sheets, pastes, and
powders. The sheets are conformable for easy application and help reduce
pain at the wound site; shaped sheets are available for awkward areas
such as the heel and elbow.13 Pastes and powders tend to have
a greater absorptive capacity than the sheets and are usually used to
fill cavity wounds to the surface.3

Hydrocolloid wound dressings are best for granulating and
epithelializing wounds with low-to-moderate amounts of exudate. They
should not be used for dry wounds or exposed bone or muscle.3,13 Since they are occlusive, patients can shower while wearing a hydrocolloid dressing.12

These dressings break down to produce residue of various colors and a foul odor that may sometimes be mistaken for an infection.12 Hydrocolloids containing gelatin from pigs may not be acceptable to vegetarians and patients of some religious backgrounds.3 The frequency of changing the sheets depends upon the level of exudate and is usually between 5 and 7 days.

Alginates: Alginates are made of soft,
nonwoven fibers derived from different varieties of seaweed and are
available as pads, ropes, or ribbons.7,10 Alginates are
either mannuronic or guluronic acid. Since they can absorb up to 20
times their own weight in fluid, they are particularly useful for highly
exudating wounds.3 They absorb the wound exudate and form a
gel-like covering over the wound, maintaining a moist wound environment.
Unlike gauzes, alginates do not physically inhibit wound contraction.7

Alginates require a secondary dressing, and care should be taken to leave room for expansion when packing cavities.15 Alginates should not be used with hydrogels that will add fluid to the alginate and reduce its fluid-handling capacity.3

Film Dressings:Transparent adhesive
film dressings are made of polyurethane and are semipermeable membrane
dressings that are waterproof yet permeable to oxygen and water vapor.13 They maintain a moist wound environment and help prevent bacterial contamination.11,13 These films facilitate cellular migration and promote autolysis of necrotic tissue by trapping moisture at the wound surface.11

Film dressings are best for superficial wounds; wounds
with light exudate; wounds on the elbows, heels, or flat surfaces;
covering blisters; and for the retention of primary dressings,
especially hydrocolloid
and alginates, as they provide waterproof cover.16
Film dressings cannot be used for wounds with moderate-to-heavy exudate
and must be selected carefully, as some newer films are intended for IV
sites and may dry up the wound. They are usually changed up to 3 times
per week.13

Foam Dressings:Foam dressings are highly absorbent dressings usually made from a hydrophobic polyurethane or silicone foam.13
They are useful for heavily exudating wounds, particularly during the
inflammatory phase following debridement and desloughing, when drainage
is at its peak.13 Foams are also effective in the packing of
deep cavity wounds to prevent premature closure while absorbing exudate
and maintaining a moist environment, and in weeping ulcers such as in
venous stasis.17

Foam dressings rarely adhere to the wound bed and are conformable and very comfortable to wear.3 They can be worn during bathing and can frequently be left undisturbed for 3 to 4 days.13

Protease-Modulating Dressings:Proteases
(e.g., matrix metalloproteinases) are associated with angiogenesis and
the natural debridement and cleansing of wounds.3 Matrix
metalloproteinases degrade collagen and other components of the
extracellular matrix and assist in tissue remodeling by allowing cells
to move through the wound bed.8,18

Compression Dressings:Compression dressings are layered primary dressings that are used to apply compression in the treatment of venous ulceration.10
They vary in the amount of stretch they provide intrinsically and
extrinsically, and correct application is essential for maximum
effectiveness. They may consist of two or more of the following layers10:

• First layer: a natural wool layer, which is
subcompression wadding bandage used to absorb exudate and redistribute
the pressure around the ankle; applied in a loose spiral

• Second layer: a crepe bandage that increases absorbency and smoothes the orthopedic wool layer

• Third layer: a light compression bandage

• Fourth layer: an elastic cohesive bandage that keeps all the layers in place.

Antimicrobial Dressings:Dressings
impregnated with antibacterials, such as silver or iodine, are targeted
at preventing infections. Additionally, topical bacitracin, polymyxin B,
neomycin, and their compounds may be formulated into an ointment. These
dressings are soothing, comfortable to wear, lubricating, occlusive,
and deliver the antibiotic directly to the wound. They are effective in
limiting scab formation. Silver may be added to alginate, hydrofiber,
hydrocolloid, foam, and activated charcoal dressings.19 Silver exerts its antibacterial effects by9:

• Interfering with bacterial electron transport

• Binding to DNA of bacteria and their spores, increasing the stability of the double helix and impairing replication

• Interacting with the bacterial cell membrane and damaging the structure

• Forming insoluble, metabolically ineffective compounds.

It is important that the minimum effective amount of silver be applied to reduce systemic absorption, as silver may be toxic.9
Some patients may find the gray discoloration, formed when the silver
reacts with pollutants in the environment to form silver sulfide,
unpleasant.9 Silver dressings are used for 2 weeks and then
the wound is reassessed. They should not be used in patients receiving
radiotherapy, x-rays, ultrasound, and diathermy.19 Since
silver is inactivated by protein binding, dressings that release silver
slowly need to be changed less frequently than those that immediately
release silver.9

Examples of each of the dressing types reviewed are provided in TABLE 3.11,13,20

Other Wound Management Techniques

Vacuum-Assisted Wound Closure (VAC):This
technique is a type of topical negative pressure therapy based on the
theory that the application of negative pressure either continuously or
intermittently can speed up the healing process.19 A vacuum
is applied across the wound together with a specially designed foam
dressing or moistened gauze connected to a vacuum machine by tubing. VAC
is useful in enhancing blood flow, diminishing edema, limiting
bacterial proliferation, and accelerating granulation and the formation
of tissue in the wound.19

Larvae (Maggot) Therapy:Larvae
therapy uses sterile fly larvae (maggots) to debride necrotic and
sloughy wounds effectively and quickly, and in many cases it removes the
need for surgical debridement.21,22 The maggots break down
dead tissue by releasing proteolytic enzymes to digest it and promote
the formation of granulation tissue.21 The maggots die very
quickly and therefore should be applied the same day they are delivered.
A nonocclusive dressing should be applied over the maggots, as they
require oxygen to survive. The periwound area should be protected,
because healthy skin can be damaged by the maggots.21

Larvae therapy can be used for purulent, sloughy wounds on the skin.23
The process takes about 3 to 5 days and requires close monitoring. The
outer dressing should be changed as required to prevent the maggots from
suffocating, and patients should be careful not to squash the maggots,
especially at pressure sites.21

Larvae therapy is quick, efficient, and effective.
Furthermore, it breaks down bacteria, thereby reducing malodor. This
therapy, however, can be painful owing to the changing pH; patients may
be prescribed a simple analgesic such as acetaminophen to ease the
discomfort. Some patients and health care prescribers may be hesitant to
use this therapy for fear of contact with maggots.21-23

Conclusion

With the large number of wound management products
available in the market today, it is important that health care
professionals be conversant with their function and application. It is
well recognized that no one dressing has all the properties of an ideal
dressing, but advances in technology have led to the development of
techniques such as VAC and larvae therapy over and above the use of
basic wound dressings.

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